1. Hospital Quality measured by:
Medicare reports many issues as quality measures, and imposes financial penalties which are estimated in the hospitals' financial statements on this site: HAC, VBP, IQR, EHR, and readmissions. Unfortunately all these measures create incentives for hospitals to give less treatment to sicker patients, since sicker patients hurt the hospital's statistics and earn penalties.
Medicare reports the death rate within 30 days after a hospital stay. However their death rate excludes patients who go on hospice. This exclusion reduces the apparent death rate, and creates a strong incentive for hospitals and doctors to urge the sickest patients onto hospice, whether they have a real chance of cure or not, since deaths on hospice don't hurt the hospital's statistics. As with most medical incentives, medical staff who urge hospice do not reveal their incentives. (methods)
US News and World Report does not show an exact death rate, but shows hospital death rates (within 30 days) in deciles for particular diseases. They do not exclude hospice or palliative care, so they don't create an incentive for hospitals to hide deaths by referring to hospice. They generally omit transfers from other hospitals, to avoid high death rates in major hospitals which receive many transfers of the very ill. So they are trying not to penalize hospitals which serve the sickest patients. They adjust to reflect all patients, not just the elderly, and slightly adjust to reduce random variation in the smallest quarter of hospitals. (methods)
Consumer Checkbook (subscription $22 for 2 years) shows hospitals' exact risk-adjusted death rates (within 90 days), for medical patients, surgical patients, and combined, based on 10 serious medical diagnoses and 14 surgical. They use Medicare patients from Oct 2009 - Sept 2012, and do not exclude hospice or palliative care patients, so hospitals can't hide deaths by referring to hospice. They also show a combined "adverse outcomes" rate for surgical patients, the total of deaths, atypically long stays, which indicate major complications, and readmissions within 90 days of initial hospital discharge. Penalizing readmissions does penalize care for the sickest patients, who are more likely to need another hospital stay within 3 months. (methods)
Ratings of doctors by Checkbook, ProPublica and others are discussed on another page.
Hospitalinspections.org counts and describes "deficiencies cited during complaint inspections at acute-care, critical access or psychiatric hospitals throughout the United States since Jan. 1, 2011. It does not include results of routine inspections or those of long-term care hospitals. It also does not include hospital responses to deficiencies cited during inspections." (emphasis added)
Healthgrades does not show an overall death rate, but reports hospital death rates for over 20 diagnoses. For non-surgical diagnoses, they ignore deaths of patients discharged to hospice. Starting in 2014 they no longer ignore deaths of patients who saw a palliative care doctor in the hospital. Through 2013, for half of diagnoses, they omitted patients from the death rate who saw a palliative care doctor in the hospital (methods: 2014 and 2013).
Healthgrades has a risk calculator for 6 common surgeries, which shows hospitals near you with low rates of death and complications, and it shows high-volume doctors at those hospitals. Their definition of high volume is a mix of high volume on the procedure you need along with total volume for all procedures. You can get more specific information on experience with these 6 and all other procedures on another page.
NICHE (Nurses Improving Care for Healthsystem Elders) lists hospitals which have adopted strong programs in Geriatric nursing, so they offer better care and healing for seniors. Many of these hospitals have Acute Care for the Elderly (ACE) units. They encourage walking, try not to interrupt sleep, and they minimize prescriptions. They encourage hospitals to help caregivers as well as patients. The search function at NICHE does not show which hospitals have exemplary programs, nor even the closest programs, so here is a spreadsheet.
Leap Frog Group asks hospitals how well they comply with certain quality standards, and has answers for about a quarter of hospitals. (methods)
Dartmouth Atlas has multiple lists with unique information on hospitals:
- Types of health care used during last 2 years of life by Medicare patients who died in 2010. Also some earlier years. This shows use of doctors, hospitals, nursing homes, hospice, home health: average days and spending. (methods)
- Readmission rate, and use of doctors during 30 days after discharge from a hospital, for Medicare patients who were admitted in 2010. Also some earlier years (methods)
Consumer Reports (subscription $7/month or $30/year) groups Medicare data on readmissions into categories, and shows many hospitals at once, so it may be easier to use though less precise than the Medicare site. (methods)
Truven, (subscription) formerly part of Thomson Reuters, now uses Medicare data on deaths and readmissions (methods) at hospitals.
Chest surgeons show 3-star ratings on about 500 hospitals and 500 group practices (typically the group of surgeons operating at a hospital), for
- Coronary artery bypass grafts (CABG) and
- Aortic valve replacements (AVR).
Cardiologists show 4-star ratings for use of recommended drugs by a few hospitals after
- Implanting Cardiac Defibrillators, and
- Diagnostic Catheterization and Percutaneous Coronary Intervention (PCI/Angioplasty)
California rates hospital quality on:
- hip/knee replacments: Medicare 30-day unplanned readmissions, all ages' surgical site infections, and 8 Medicare patient complications: heart attack-7 days, pneumonia-7 days, sepsis/shock-7 days, surgical site bleeding-30 days, pulmonary embolism-30 days, death-30 days, mechanical complications-90 days, joint/wound infections-90days
- childbirth: cesareans (spelling), episiotomies, breastfeeding in hospital, vaginal birth after cesarean, cesarean infections.
- colorectal cancer screening of adults 50-75
- lower back pain patients who had X-ray, MRI, or CT scan within 28 days of the diagnosis (fewer is considered better)
- diabetes/blood: kidney function screenings, HA1c blood sugar testing, HbA1c <8.0%, blood pressure <140/90, cholesterol screenings, cholesterol LDL-C <100
Luxury Suites are available at many hospitals for $250 to $2,500 extra per day.
Review article in 2010 covered similar information at that date. It recommended that hospital staff should learn how hospice and palliative care affect the ratings from each group, so each hospital can get ratings as high as possible.
2. Other Incentives to Leave Patients Untreated
- "Patients who are not receiving adequate preventive care will be excluded [by doctors, from getting care], and providers who take on care of these patients can be financially penalized.
- "The patients most in need of care coordination will be excluded, and providers who provide coordination to complex patients may be financially penalized.
- "Providers can be financially penalized for keeping their patients healthy...
- "[P]erverse incentive for a physician not to become involved with a patient who already incurred significant healthcare spending earlier in the year, even though these are the patients who may most need additional help...
- "Spending Measures Do Not Distinguish Appropriateness of Services ...
- "Risk Adjustment Systems Do Not Adequately Adjust for Patient Needs"
Medicare publishes death rates to help people choose safe hospitals. However they omit your death if you have been in hospice any time in the past year. It is in the hospital's interest (even if not the patient's) to promote hospice for at least a day per year to patients who they think are most likely to die. Hospice takes them out of the reported death rate. Hospitals cannot ethically suggest coming off hospice after a day, so the patient's treatment shifts to hospice.
Medical groups (ACO - Accountable Care Organizations) have a quality standard to avoid high hospital-wide readmissions (HWR) of their patients, but patients who die within 30 days of the first discharge are excluded from that standard (p.11 and p.53523). Hospitals were rated on the same measure starting October 2014. In either case when a patient is readmitted in less than 30 days, the group or hospital looks better if the patient dies within the same 30 days, so the readmission can be excluded.
Hospitals are rated on hospital-wide readmissions from all causes, and some procedures have more readmissions than others, especially among the elderly, so hospitals have an incentive to minimize these procedures.
Healthgrades death rates ignore your death if the hospital has sent a palliative care doctor to see you, or if you are discharged to hospice. Hospitals know that some consumers use Healthgrades to evaluate hospitals, so they have an incentive to promote palliative care and hospice.
Consumer Checkbook hospital data, ProPublica surgeon data, and US News and World Report do not exclude hospice or palliative, so they provide a more complete picture, and less incentive to push patients into hospice.
The US Department of Justice prosecutes hospitals and doctors for billing Medicare for care outside Medicare guidelines, even if appropriate under other expert guidelines. The investigations chill the willingness of doctors to provide care.
3. Doctors' Quality
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